VenousLinesbe inserted

VenousLinesbe inserted Gentral CanPeripheral ullywherex-rayfacilitiesarenot safelyandsuccessf available? Abstract Boon,JM Medicine) MBChB,MMed(Family Departmentof Anatomy,Unit of ClinicalAnatomy,Schoolof
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VenousLinesbe inserted Gentral CanPeripheral ullywherex-rayfacilitiesarenot safelyandsuccessf available? Abstract Boon,JM Medicine) MBChB,MMed(Family Departmentof Anatomy,Unit of ClinicalAnatomy,Schoolof Medicine,Facultyof Health Universityof Pretoria Sciences, MamelodiHospital,Department Facultyof of FamilyMedicine, of University HealthSciences, Pretoria Kirkb; RE MBChB,MPraxMed.MFGBDA, (Pharmacol), BSc(Hons) Medicine) MSc(Sports Dept FamilyHealth,KingFaisal Hospitaland Research Specialist SaudiArabia. Centre,Riyadh, Correspondence to: D r J MB o o n 0 34, PO BOX 3 l0gg,totiusdal Pretoria,SouthAfrica Tel: Fax: Keywords: centralvenouscatheterisation, peripherally insertedcentral catheters,primary care physicians Background: Primarycaresettingsoften lackfacilitiesfor radiologicalevaluationof the insertedcentralyenouscatheters' positionof supra-andinfra-clavicularly lf peripherallyinsertedcentralvenouslinescould reliablybe successfully inserted this would make the need for immediate confirmatory radiologicalstudies less crucial. Previousstudies with peripherally insertedcathetersreporteda low successrate.thisstudywas performed to determinewhether the placementof a more flexibleperipherally l), would resultin an the Arrow PICC (Arrow PS-O165 insertedcatheter, successrate. improvedandacceptable Method: Twenty-threepatients in the casualtyunit of the Mamelodi Hospital during 1997and 1998,who requireda centralvenousline and had this insertedvia the peripheralvenousroute were evaluatedafter insertionof The best basilicor mediancubitalvein in the cubitalfossa the catheter. method.anumberof l4 was usedfor insertionfollowinga standardized catheterswere insertedin the right arm and 9 were insertedin the left by an AP supinechest arm.the positionof the place.e-ntwas assessed X-ray. Results: Successfufplacementwas achievedin 9l% of insertions (21 of 23 catheters). placements the cathetertip was locatedin the In both of the unsuccessful ipsilateralinter.naljugularvein.(one on the left and one on the right') No resultedfrom theseprocedures. signifi cantcomplications clinically Conclusions: with soft catheters This studyshowedthat centralvenouscatheterisation peripheral veinsin palpable via visible (ArrowPlCC-Arrow PS-O1651), procedure with a high the cubitalfossais easyto perform and is a safe success rate for correct catheter placement.this route warrants seriousconsiderationwhen central venouscatheterisationis desirable, especiallyin settingswhere X-ray facilitiesare not availableto exclude or confirmplacement. complications SA FomProa2002,25(4):4-8,wlntroduction re: extremely valuable', but correct olacementis essentialfor accurate monitoring. Central venous lines are used for the accurate monitoring of fluid administration in variousclinicalsettings'.lt is Insertionis usuallyeffectedvia the infraclavicular supraclavicular or routes. Complications,such as pneuhemothorax, catheter mothorax, e m b o l i s mv, e n o u sa i r e m b o l i s mn, e r v e injury,arterial puncture and chylotho- rax. have all been documented following catheter insertion via these routes'. In an article discussing complications associated with central venous catheters, Scoft states that a Chest X-ray is mandatory to exclude immediate complications for e.g. a pneumothorax 4. Strong warnings appear in the package insert of these central venous catheters, advising that it should not be done without X-ray control. (e.g ARROW product no AK E 8192). Even standard textbooks I make the point that this procedure is potentially dangerous and requires adequate assessment. These guidelines and the weight of evidence concerning complications are a major deterrent to doctors inserting central venous lines when no X-ray facilities are available. The insertion of supra- or infraclavicular central venous lines also requires special instruction and frequent use to maintain the skill and expertise to perform these procedures. Radiological control is often not available in primary care environments, especially after hours. Rosen' has shown that the insertion of central venous lines via the cubital fossa (peripherally inserted central catheters) is safe and has a low complication rate, similar to the insertion of a normal drip. However, previous studies with peripherally inserted catheters reported a low success rate - 77,7% correct placement with a Drum cartridge catheter, and 52,8% with the l-catheter (Bardic)'. X-ray assessment following catheter insertion is performed to exclude the complications listed above and to ascertain whether the catheter tip is in the desired position. Major complications needing X-ray assessment are unlikely to occur following peripheral venous insertion, so the major reason for X-ray assessment is to determine the correct placement of the catheter tip. lf peripherally inserted central venous lines can be successfully inserted (i.e. the catheter tip in the correct position to monitor central venous pressure), the necessity for radiological evaluation is far less critical. This will be of tremendous help to primary health care doctors without radiological control facilities. Some authors have suggested that a medial cubital vein should be used in emergency conditions to reduce the number of complications'. Cannulation of the superficial veins of the arm require less skill than cannulation of the subclavian and internal jugular routes'. Peripherally inserted central venous pressure has been shown to reflect central venous pressure quite accurately under controlled circumstancest. Rosen' argues that for short-term use, central venous catheterisation through visible palpable peripheral arm veins is safe and remains the method of choice for those with little experience of sophisticated techniques. Primary care doctors are not always exposed to and therefore often have little experience with sophisticated techniques. This study was prompted by the fact that Mamelodi hospital has no X-ray facilities after 4 pm in the afternoon and practitioners working there have to deal with many patients who would benefit from the insertion of a central venous line. We believe there are many such settings where primary care doctors have to work in less than ideal circumstances and also have not had exposure to training in the insertion of catheters via the supra- or infraclavicular routes. lf we can find a method with the safety and the lack of major complications that peripheral vein cannulation offers but with an acceptable accuracy of placement of the catheter tip to ensure the benefits of central yenous pressure monitoring, this would have obvious benefits. The aim of this study was to determine whether the more flexible Arrow PICC (Arrow PS-0165 Peripherally Inserted Central Catheter) could be safely inserted via a peripheral vein with the catheter tip placed successfully in the desired position in the superior vena cava. Materials and methods. The Arrow PICC catheter was inserted in 23 patients needing a central venous line.thearrow PICC (Arrow PS-O165 l) is a soft polyurethane radiopaque catheter, 55cm, l6ga (Figure l).the. study was performed in the casualty unit of the Mamelodi hospital during.997 to Informed consent was obtained from all patients or their family prior to insertion of the catheter and the study was approved by the Ethical Figure l.' TheArrow PICC (Peripherally inserted central catheter) (Arrow PS-O165 l) with syringe, cannuland catheter (arrow heads). Figure 2: Figure 2.Anatomy of the superficial veins of the arm. Committee of the Faculty of Medicine of the University of Pretoria. A method described by Rosen' was used to insert the catheter. which is as follows:the best basilic or median cubital vein of the cubital region on either the left or right side was used (Figure 2).The patient was positioned in a supine position, with the arm abducted 45' and the head turned towards the side of insertion. Patients with suspected neck injuries were therefore excluded from the study. The insertion was performed under sterile conditions. One catheter was inserted by REK and all the others by JMB. No additional training was necessary in advance. The procedure is Figure 3: Removal of cannula (arrowhead) after catheter insertion. 4.' Supine AP Chest X-ray demonstrating the catheter from the right side (arrow heads) and the position of the catheter tip (arrow). simply the same as inserting a ordinary 4-GaJelco intravenous catheter in the basilic or median cubital vein in the cubital fossa. The cephalic vein was avoided because of a lower success ratet. due to the vein coursing through a 90' angle in the deltopectoral triangle and again through the clavipectoral fascia to the axillary vein. The correct length of the catheter was determined by measuring the catheter in its sterile packing on the patient.the catheter has marked calibrations, which allows for accurate measurement of the length of catheter required to be inserted into the vein. The measurement was estimated from the insertion site in the cubital fossa, following the route of the vein through the arm, axilla, and infraclavicularegion, to a point to the right of the sternal angle. The Arrow PICC(Arrow PS-0165 l) is a catheter-through-cannula device. The venepuncture is performed using a short needle encased with a cannula (similar to a l4ga Jelco needle). A syringe attached to the needle can easily detect successful venepuncture (Figure l). The cannula tip is fairly sharp and rigid to enable it to penetrate the skin and wall of the vein. This allows the catheter that is subsequently inserted through the cannula to be of a much safer material and design.the needle is removed before the catheter is inserted, consequently eliminating the risk of damaging the catheter. The catheter is inserted through the cannula into the vein. After the catheter is inserted the cannula is removed (Figure 3). No resistance is noted on advancing the catheter. Blood was freely aspirated from the catheter after insertion. When measuring the central venous pressure oscillations, synchronous with the respiration and pulse is observed. A supine AP chest X-ray (Figure 4) was taken afterwards to determine the position of the catheter tip and to determine any immediate complications. Correct placement of the catheter tip rate.there were no significant clinical was defined as placement of the complications and only three patients catheter tip in the superior vena cava, suffered from superficial inflammation 3-4 cm above the entry into the right at the insertion site. atrium, with the distal portion of the catheter positioned parallel to the One obvious limitation of this study vessel wall'0. The position of the is the number of catheter placements catheter was considered unsatisfactory if it assumed any other position 94 done by Ng and Rosen6, the 50 (23) studied when compared to the e.g. in a peripheral vein, in an internal used by Burgess and the 50 used by jugular vein or in the heart. Bridgesr'?. A number of 14 catheters were inserted from the right and 9 from the left.,.*itrresults.mdiscussionre This study resulted in a high success rate (9l%) and a low complication However this study was performed in a primary care setting and because the authors performing the study work mainly in an environment Each patient was followed up after where confirmatory X-rays are not hours to check for any complications. All patients were examined numbers where confirmation of available (Mamelodi), obtaining patient clinically. placement is possible hampered the recruitment of patients. In addition this study was performed There were thirteen successful by primary care physicians with no catheter placements in the right arms special training in intravenous techniques.this may have more relevance of patients and eight on the left (Table l). The two unsuccessful placementsfor other primary care physicians resulted in the catheter tip lying in than studies conducted by experienced anaesthetists and intensivists in the ipsilateral internal jugular vein (Table l). One failure was from a large centres. catheter inserted from the right side and one from the left. The mean length for catheters inserted on the right was 38 cm, and on the left 48 cm. No early complications were recorded. Three patients developed a superficial inflammation at the insertion site ordinary after 48 hours. Our success rate for correct placement of the catheter tip was 9l%(21 out of 23). Tdble l: Results of catheter placements. N Reasons for the high success rate may be the performance of most insertions by one operator (JMB). No additional training in intravenous technique was however needed, due to the fact that insertion of this catheter in the basilic or median cubital vein is similar to inserting an l4-ga Jelco intravenous catheter. One catheter was inserted by another operator (REK) without any problems. Difficulties to insert these catheters are the same for intravenous cannulation and could therefore be performed by any doctor who is skilled to insert intravenous lines. Successful placement Right t4 t3 I Left 9 8 I Total 23 2l 2 Unsuccessful placement : Care was also taken to adhere to the following prlnciples: l. lt is impoftant to measure the length of the catheter as precisely as possible. The position of the catheter is deemed unsatisfactory if it lies in a peripheral vein, in an internal jugular vein, or in the heart. Inserting too great a length of catheter especially from the right may lead the catheter into the right atrium, ventricle or even enter the pulmonary arteryr3. Most frequently mal-positioned catheters inserted through the arm veins find their way to the ipsilateral internal jugular vein. Both misplaced catheters in our study were found to lie in the ipsilateral internal jugular vein. 2. The patient should be in the correct position when inserting the catheter.woods et alra showed that especially when the basilic vein was used, the 45' abducted arm improved the success rate. Dietel and Mclntyre'' found that turning of the head towards the side of venepuncture reduced the chances of the catheter entering the ipsilateral internal jugular vein. The value of these various manoeuvres has been proven with catheters inserted via the basilic vein under fluoroscopic control''. These procedures were part of the insertion protocol and were followed with all placements, including the failures. lf the catheter tip is not correctly placed, central venous pressure can not be accurately recorded. However, no major immediate complications will result and the line may serve as an intravenous line for some hours. The clinical observations we performed, i.e. measuring the venous pressure with the observation of oscillations synchronous with pulse and respiration, did not help us detect the failures. 3. The type of device used appears to be an important factor in determining the success rate of cannulation through arm veins. Studies show that the more rigid devices cubital vein should be used in emergency conditions to reduce the num- like the -catheter'do not demonstrate as high a success rate as the ber of complications'. Cannulating the softer more flexible catheters12.wesuperficial veins of the arm require used the Arrow PICC which is also less skill than the subclavian and a soft type of device. Our success internal jugular routes'. rate supports this statement. The Arrow PICC is a safe catheter. lt 4. Reading of the central venous pressure should be'done with the arm The catheter is not inserted through is a catheter-through-cannula device. in 45 abduction. Further abduction a needle device. Therefore the or adduction ofthe arm can lead to catheter cannot shear if aftempts are movement of the catheter tip up to made to withdraw it while the needle 2-3 cm.adduction alone can result is still in the vein.there is no flexible in the catheter being drawn into stylet wire stiffening the catheter the thorax as much as 9 cm'7. throughout its length. There is a risk of air embolism after the syringe is removed and the cannula is situated in the lumen of the vein and the proximal end is open to the atmosphere. This is usually the case with most central venous lines irrespective of their place of insertion. The central veins are however prevented from collapsing because of connective tissue surrounding them. Air embolism is therefore more likely to occur in them than the peripheral veinsrs. Authors have suggested that a medial t. Rosen M, Latto P. Handbook of percutaneous central venous catheterisation. 2nd ed. London, Philadelphia, Toronto, Sydney, Tokyo: W.B Saunders Company; Kalso E. A Short history ofcentral venous catheterisation. Acta Anaesthesiol Scand 1985; 8l:7. Dawood MM, Trebbin WM. Complications associated with central venous cannulation. Hosp Pract 99 ; 26:2-2 4,2 l Scott WL. Complications associated with central venous catheters. Chest 1988:94: Rosen M, Latto P. Handbook of percutaneous central venous catheterisation. 2nd ed. London, Philadelphia, Toronto, Sydney, Tokyo: W.B Saunders Company; 1992:58. Ng WS, Rosen M. Positioning central venous catheters through the basilic vein. A comparison of catheters. BrJ Anaesth 1973;45:l2l t. Editorial. Central Vein Catheterisation. Lancet 1986;2:669. References Joseph DM, Philip BK, Philip JH. Peripheral venous pressure can be an accurate estimate of central venous pressure. Anesthesiology 1985; 65:A 166. Webre DR, Arens JF. Use of cephalic and basilic veins for introduction of central venous catheters. Anesthesiology 973; 38:389. Blitt CD. Monitoring in Anesthesia and Critical Care Medicine. Central venous pressure monitoring. New York: Churchill Livingstone; 1985: l2l Burgess GE, Marino RJ, Peuler MJ. Effect of head position in the location ofvenous catheters inserted via basilic veins. Anesthesiology 1977 ; 46'212. t2. Bridges BB, Carden E, Tackacs FA. lntroduction of central venous pressure catheters through arm veins with a high success rate. Can Anaesth SocJ f979;26:128. t3. Farman JV. Which central venous catheterl BrJ Clin Equipment 1978; 32:210. thirds of the price of a standard CentralVenous Line Catheter Set. l1ffigonclusigp INrr We think that despiie our small numbers this study confirms that central venous catheterisation with a soft peripherally inserted intravenous catheter (Arrow PS-01651) through visible palpable peripheral arm veins in the cubital fossa is safe and easy to perform. It has a low complication rate and a high successful placement rate. Three cases developed superficial Accordingly it merits serious consideration especially in situations where inflammation at the site of insertion. None of these three developed trombophlebitis. A superfi cial inflammation X-ray facilities are not immediately available and a central venous line is is not an indication to remove the considered to be imperative. We catheter. However if signs and symptoms of severe local infection and would also hope that further studies could be conducted on a larger body systemic infection appear, the of patients to better assess the promise of this technique. catheter should be removed''. An aseptic technique should be followed, and the catheter should be removed as soon as it is no longer needed. Acknowledgements rl Using the PICC Catheter Set (Arrow PS-0165 l) proves to be cost-effective. Arrow SA for providing the The cost of the catheter pack is two catheters il. t4. Woods DG, Lumley J, Russell WJ, Jacks RD. The position of central venous catheters inserted through arm veins: a preliminary report. Anaesth Intensive Care 1974;2:43. t5. Deitel M, Mclntyre JA. Radiographic confirmation of the site of central venous pressure catheters. Can ) Surg 197l; 14:42. t6. Ragasa J, Shah N, Watson R, Bedford MD. Where antecubital CVP catheters go: a study under fluoroscopic control. Anesthesiology 988; 69(Suppl.3A):A23 t7. Kalso E, Rosenberg PH, Vuorialho M, Pietila K. How much do arm movement displace cubital venous catheters
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